PPO Select Value® CareSM

Policy Form Number: PPO-IND-VALUE

General Benefits

In-Network Benefits Out-Of-Network Benefits
PPO Select Value Care pays 50% and you pay 50% of eligible expenses PPO Select Value Care pays 50% and you pay 50% of eligible expenses

Physician office visits paid at 50/50 coinsurance.

Physician office visits paid at 50/50 coinsurance.
Network providers will preauthorize your medical care. You must preauthorize hospital admissions and certain services.
Usually no claim forms to file You may have to submit claims for reimbursement
Emergency room visits within 48 hours of accident paid at 50/50 coinsurance. Emergency room visit within 48 hours of accident paid at 50/50 coinsurance.

Individual & Family Plans Only

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